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HomeMy WebLinkAbout0399 NOTTINGHAM DRIVE - Health 399 Nottingham Drive Centerville A= i E: f UPC 12534 � .2.153E OMMOLW � TOWN OFF BARNS-TABLE /Na ' ,LOCATION ' / l" ',�-7y7�? 01A1 - SEWAGE# — 97 VILLAGE �GN/BIZ-�J/ctl�� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. '7?57" Z Fr 6 a SEPTIC TANK CAPACITY (.-,:-V QY.;' 4,04 LEACHING FACILITY:(type' JA11QrCAib(2- 306-D'5 (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Per 21gy, Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 1U Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by >Va?li,)vWW Orive q No. t � � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTAB -MASSACHUSETTS Yes n ZIppYfcation for Mtgpogal *p5tem Cougtructtort Permit Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑Complete System Individual Components Location Address or Lot No. l /'l/O /!IG'j h'4 m f% Owner's Name,Address,and Tel.No. Assessor's Map/Parcel "7 — ( 6or"r4�S�t ()gq Installer's Name,Ad&s6 a.GAN 0 Designer's Name,Address and Tel.No. 355 Main Street pieler e5; 36d- a �'aa , . MA 02673 Type of Building::.::, Dwelling No..of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures q Design Flow(min.required) �j 1196 gpd Design flow provided �3 y • / 6 gpd L Plan Date �7 S Number of sheets t Revision Date Title / Size of Septic Tank %If n Type of S.A.S. Description of Soil ��1— P14h Nature of Repairs or Alterations(Answer when applicable) A,r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board ot�Health Sign /� Date l ,� Application Approved by OLM ZV4 Date Application Disapproved by: Date for the following reasons Permit No. 1 Date Issued 0 '' No a �`-r �' ` ,,r ; 's �' - .'.• Fee X t THe, CE OMMONWEALTH OF MASSACHUSETTS Entered in computer: s aw..� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTA8_LYT ASSACHUSETTS ZIPpYication for gigogal 16p5tem Cou.5truction Permit ..Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ❑Complete System Individual Components Location Address or Lot No. 3�'� �/1/0/T/GI ( A m Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ''� — 6o f��4 �S�� U8y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow(min.required) �j gpd Design flow provided 33 -/ /Q 6 gpd Plan Date /U 7 Number of sheets / Revision Date "VI q Title Size of Septic Tank Type of S.A.S. Description of Soil * Nature of Repairs or Alterations(Answer when applicable) l - Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of . Compliance has been issued by this Board oNHHealth. Sign J Date f Application Approved by / W �/K j Date Application Disapproved by: v Date for the following reasons Permit No. ! Date Issued 0 0 Do ——————————————————————————————i————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded Abandoned( )by � at 322 9 /(/(J/T i i hg,, /Jr. �e,��.{Pt has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. � dated Installer ( er i^! C y Designer rn40 #bedrooms 3 Approved design flow _ gpd The issuance of this permit shall not be,'construed >a g a antee that the system wil'1 fun do'hsr`d signed. Date / Inspector _ No. AM)5�'l/."� _ Fee /0 U HE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS wigoar �§pgtem Cow5tructiom Permit Permission is hereby granted to Construct ( Repair ( ) Upgrade (Abandon ( ) System located at O i. h,-h'7 F, �- r` v� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructidn must bee��com leted within three years of the date of thisGerrdVa Date C/ Approved by Town Of Barnstable tHE Ty Regulatory Services . O Thomas F.Geiler,Director l 16 .. " Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 12 /5 105 Designer: NWA M ■0 l , I55nstaller: Address: . T ,Q. IV Address: 350 Main Street G W. Yarmouth, 673 � �wt1,4 AM- On �(/ WL o was issued a permit to install a (dat ) (installer) septic system at l l fie r/-1lygeli4l"i lJie V`f based on a design drawn by (address) . a_ K a o �. � �i✓ dated /0 • (designer) • - - X1-certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the �( distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. LAN OF M,1 Y%moo?� ARREN a M, (Installer's Signature) Y1 0 C �GISTE1� IY sgNI TAR\PN• (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC ]HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH -THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH`DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form - I 1 Y Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, I Yv l• p"V Li ,hereby certify that the engineered plan signed by me dated 1-7 0 , concerning the property located at Now Kt 1e meets all of the following criteria: a' • Two soil evaluations excavated for detailed examination(no hand augering) and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated.with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed _ • There are no variances requested or needed. , r • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: c 0 A) Top of Ground Surface Elevation(using GIS information) J B) G.W. Elevation ✓J.D+adjustment for high G.W. = N 96 u) VJ t a DIFFERS CE BETWEEN A and B SIGNED D� ATE: O 3 0 5 NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc __ Ilk Too r� Town Of Barnstable o�tHE:rc Regulatory Services ... Thomas F. Geiler,Director +: BA STABLE, g ]Public Health Division �O Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-63©4 Installer & Designer Certification Form Date: OS Designer: Ngup� M , Installer: V Address: . ZO. 49 V Address: 350 Main Street Yarmouth, M 673 On was issued a permit to install a . (dat ) -� (installer) septic system at �� ( Ale rt Neeq.., BW c V e based on a design drawn by (address) A-1, M4 ZI dated l d (designer) certify that the septic system referenced above was installed substantially according to fhe design, which may include minor approved changes such as lateral relocation of he distribution box and/or septic tank- the certify that the septic system referenced above was installed with major changes (i.e, greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. LZH OF.MAS no ARREN ctiGN a M. (Installer's Signature) 1 Y R 1 � �o. 1 00 FG/STE¢� SgNITAR\P� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH DTVISION. THANK YOU. Q:Hea1th/Septic/Designer Certification Form °FINE t �Y Town of Barnstable * BARNSTABLE, * Regulatory Services y MASS. ib39. 10 Thomas F. Geiler,Director rFD MA'S A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 1, 2005 Ms Susan White 471 Shoot Flying Hill Road Centerville, MA 02632 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 399 Nottingham Drive, Centerville, MA was inspected on August 11`h 2005 by James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed"under guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: The original leaching pit was full and backing up into the Distribution Box. There were signs of hydraulic failure. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder, please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT TOWN OF BARNSTABLE pLOCATION !//��- ��� SEWAGE# .VILLAGE . t-417 ASSESSOR'S MAP&LOT A �R'S NAME&PHONE NO. /n r 11/6 C" /� a SEPTIC TANK CAPACITY '� £ 7/ c-- c / O,t, LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER Itf 5 PE4i*KT DATE: DATE: r� 0 7� Separation Distance Between the: J►►/� .f-- i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by s { � _ ��°°�� 3t� �� �� �' i o d4 - kpW 5� �b os- -7 7 COMMONWEALTH OF MASSACH.USETTS z i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS w rc a DEPARTMENT OF ENVIRONMAINTAL PROTECTION e� ,�qM cV 0 y 350 MAIN S"I.R- 'ET A WEST YARMO`UTH,MA 508-775-2800 Li d TITLE 5 OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP—171—PARC 084 Property Address: 399 IJOTTINGHAM DRIVE c� CENTERVILLE,MA 02632 O,nmer's Name: GOitASKI,CI ESTER Owner's Address: 5 DRURY LANE STONEHAM,MA 02180 Date of Inspection JUI,Y 29,20U Name of Inspector:(please print) JAMES D.SEARS Company Name: A&13 Canco Mailing Address: 350)Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally i:ispected the sewage disposal system at this addre_.s,and that the information reported below is true;accurate and convi-te as of the time of the inspection. The inspection was perfonued based on my training and experience in the pi oiler function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes 1 Needs Further Evaluation by the Local "approving Authority Fails Inspector's Signature: Date; 7`�� OS The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to tile.system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments " This report only describe,conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future up.der the same or different conditions of use. Title 5 Inspection Form 6/15!2000 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 399 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: GORASKI,CHESTER Date of Inspection: JULY 29,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all oi"Section D A. System Passes: N/A I have not found any infonnation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N.ND)in the for the following statements. If"not detennined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is stnucturally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain.- The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstniction is removed ND explain: Title 5 Inspection Form 6/15/2,000 2 f . Page 3 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 399 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: GORASKI, CHESTER Date of Inspection: JULY 29, 2005 C. Further Evaluation is Required by the Board of Health:N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board bf Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance ** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2.000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 399 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: GORASKI,CHESTER _ Date of Inspection: JULY 29, 2005 D. System Failure Criteria applicable to all systems: ✓ You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 47- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pit is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Nuunber of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground,water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis mast be attached to this form.) YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. 7lne system o-mmer should contact the Board of Health to deternnine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone lI of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CNIR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 1 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 399 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: GORASKI, CHESTER Date of Inspection: JULY 29, 2005 Check if the following have been done. You must indicate"yes" or"no"as to each of the following Yes No ✓ Pumping infomation was provided by the owner;occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,including the SAS,located on site`? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ✓ Was the facility owner(and occupants if different from owner)provided with infomation on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been detennined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CNM 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 399 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: GORASKI, CHESTER Date of Inspection: JULY 29, 2005 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): .3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) NO Last date of occupancy: PRESENT C OMMERCIALANDUS TRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings;if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): TANK PUMPED AFTER INSPECTION. If ves,volume pumped: gallons—How was quantity pumped detennined? Reason for pumping TYPE OF SYSTEM ✓ Septic tank,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: N/A Were sewage odors detected when arriving at the site(yes or,no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued), Property Address: 399 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: GORASKI, CHESTER Date of Inspection: JULY 29, 2005 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 10" Materials of constriction: Cast iron ✓ 40 PVC _ other(explain) Distance from private water supply well or suction line: Cotmnents(on condition of joints,venting,evidence of leakage;etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 14" Material of constriction: _ concrete metal fiberglass s polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000-GALLON PRECAST Sludge depth: 4" Distance from top of sludge to the bottom of outlet tee or baffle: 26" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: TAPE&PROB Continents(on pumping reconnnendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORMING LEVEL,OUTLET BAFFLE SMALL OUT COVER,CENTER 18"COVER. NO SIGN OF LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: _ Material of constriction: concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Commments(on pumping reconnmendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15i2000 7 Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 399 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: GORASKI,CHESTER Date of Inspection: JULY 29,2005 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/dav Alarm present(yes or no) Alarni level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/1.5/2000 8 i f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 399 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: GORASKI, CHESTER Date of Inspection: DULY 29,2005 SOIL ABSORPTION SYSTEM(SAS): %f (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: leaching galleries,number _ leaching trenches,number,length leaching fields, number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1000-GALLON PRECAST PIT. PIT&COVER 40"BELOW GRADE. PIT IS FULL,NOT LEACHING. LEACHING NEEDS TO BE REPLACED. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionX locate on site plan) Number and configuration: Depth—top of liquid to inlet invert:, Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of constriction: hidication of groundwater inflow(yes or no): Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2.000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 399 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: GORASKI,CHESTER Date of Inspection: JULY 29, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �i 3-3-4 0 OL(5 i Tide 5 Inspection Form 6/15/2000 10 r Page 11 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 399 NOTTINGHAM DRIVE CENTERVILLE,MA 02632 Owner: GORASKI, CHESTER Date of Inspection: JULY 29.. 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 14 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked kNith local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high ground water elevation: TEST HOLE 14'NO WATER. TEST HOLE 4' BELOW BOTTOM OF [IT. BOTTOM OF PIT AT 10' BELOW GRADE. Ll Title 5 Inspection Form 6/15/2000 11 Q �a ASSESSORS MAP : TEST HOLE LOGS NOTES: 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH PARCEL : O��" p RQ SO I L EVALUATOR ;D , Wgev-,, h�7 C THIS PLAN, ` 1995 MASSACHUSETTS TITLE V & TOWN OF +F N FLOOD ZONE , 000 '7--' C BOARD OF HEALTH REGULATIONS. ,� qb , o s►i WITNESS : DT ill oQ3 o CIR bgy REFERENCE : F)Y— IA'lefl DATE :j %t j ' ( 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, IQ2ab PERCOLATION RATE: G 2 M►N INC, SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO v- C INSTALLATION. Ut f a 'j 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION p z°U - iCI�C 'im_ THE I f- .,Cv II D� TH-2l-• � ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE .. OID J �'N- M . ONAPAI) Vl L-S. (,[JRn� �� q Lottnn dp �( DETERMINATION. Is bert tid - - --_s ... cia , __. . � �. �`� "3l� . � `� � ..-. ___,..__ � �/�1d1 _ 55- 7� L.U�M 4) ALL PIPING TO BE 4" SCHEDULE 40 @ l/$ "/ FOOT. (UNLESS - _ .�� 1 c jO K{�/ SPECIFIED OTHERWISE) LOCATION MAP,OJITS!I 34') _2 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A g,q -01`zv GARBAGE DISPOSAL, WO 6) SEPTIC TANKS- AND DISTRIBUTION BOXES (WHEN INSTALLED) z �` MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON �/n . i� A BASE OF 6"OF CRUSHED STONE. "1 T T 1�T(I"J _ Imo-' 1 �?V N►►� � _ I fi Gl _ w Opp T I u- h' ? 7 ` _ �/_ ,N� No_KNoml PPOA1I�, WELL-7 VVII P) /S SEPT I C SYSTrM DES I GN �1G , w/r tom° olF7 Ppop, 1, , r FLOW ESTIMATE I�� � ��r�t� �!� � �r?ra-r _ T�� V llr� .`�, N_ OF ss .. - ._ _ 154.55 rt 1 � � BEDROOMS AT Il!O GAL/DAY/BEDROOM - 330 GAL/DAY � � (� ' t rI J�1�-�I � ( id N /4/ SEPTIC "ANK i SHED �30GAl/DAY x 2 DAYS - �'�_� GAL USE 1 0(�g GALLON SEPT I C TANK— EXI577Ak� P-E=P .AY,4: P\J/ 5er7C. TANK.. l t- Vim, tl*c. ' SOIL AB: ORPTION SYSTEM r O I✓'r 4 >- d �j 20 ft �_� ISTING 55 �x . ING �" SIDE AREA �C2 )�. 1 ,.t12Ic2 DV1�E1 � BOTTOM AREA: 25 x 2 -U o �i Top L 57. r t E m SEPT I ,C' SYSTEM SECT I ONv '. ' -� ��, 1oys- .'1, m , R R I - s , . �� ss � � Ear � '� � voc/ w11 �� � 5 2 1 ,v i µ _ i AREA 1sr 4 ., Ll _ WATER CP04oC-- /D0C) GAL c� D BOX 52 , O 0 Q Q 0 • A O 0 0 VIE AAAq �_-- I SEPTIC TANK klif 5Z ® U',�° 0 p E of FA�EM N DR -60s71Al� .� _ _ _ I�/I m_ i rEN lTTIN MARK CJ - -GH (W- CA056 5' C 71 0/� N I `INAIL F 'pK ZrTION = 54.28USGATUM ASSUMED d -� � S I TE AND SEWAGE PLAN 3/,,, '1�ca � LOCATION : a� DA RE zt Cam,y yI U_G dN _ 4uast /\MERo-1140 �2.16 fF'r _ >� PREPARED FOR 4 -( ,p a SgN(TARiP� D� T DARREN M. MEYER, R.S. SCALE •7 ®� �. P.O. BOX 981 DATE: /Q 7 0S- fllobz� f�Z u EAST SANDWICH, MA 02537 w D TECIHEAL AGENT Ph: (508) 362-2922